F.O.A.M. BLOG

Las Vegas FOAM Blog is dedicated to sharing cutting edge learning with anyone, anywhere, anytime. We hope to inspire discussion, challenge dogma, and keep readers up to date on the latest in emergency medicine. This site is managed by the residents of Las Vegas’ Emergency Medicine Residency program and we are committed to promoting the FOAMed movement.

The U.S. House is debating and scheduled to vote this week on the American Health Care Act, a bill which Speaker Paul Ryan and his allies say will “repeal and replace” the Affordable Care Act (ACA). Yet the infrastructure of the AHCA is in many ways very similar to the ACA. There are some differences, though, and we will examine those differences and what they may mean here. We will also examine the probability that this bill passes. Like the ACA, the AHCA has a system of subsidies for Americans facing high premiums for medical insurance. Under the ACA, the Department of Health and Human Services collects income data from patients and the IRS to calculate their eligibility for a premium. HHS then pays the subsidy directly to the insurance companies. Under the system envisioned by AHCA, patients would receive “monthly refundable tax credits” from the IRS which individuals would use to pay the full cost of the premium. Either way, Americans receive subsidies from the federal government to pay high health-insurance premiums (and must be fully engaged with the income tax system or risk losing the subsidies). Under the present system, premiums have risen. One potential cause is the “guaranteed issue” provision of ACA that requires insurers to cover people with pre-existing medical conditions. This removes the primary element of risk management from health insurance markets and creates a problem of “adverse selection” whereby the sickest patients requiring the most medical attention are buying into the system. Younger, healthy people have less incentive to buy insurance when they can wait to do so until they are already sick. The ACA tries to address this problem by mandating individuals buy health insurance and provide proof to the IRS that they did so. Taxpayers who didn't have insurance would have to pay the IRS either $695 or 2.5 percent of income, whichever is greater. AHCA removes the IRS mandate penalty, but still tries to mitigate the adverse selection problem by allowing insurance companies to directly charge a 30% higher premium to new customers who had let their medical insurance coverage lapse. The AHCA has one more provision to try to address this problem of adverse selection. The bill would give insurance companies wider latitude to set premiums based on age. This would be an added incentive for younger -- typically healthier – people to buy into the private insurance system by keeping their premiums somewhat under control. But between that provision and a cut in the total amount for federal money appropriated for subsidies (or “tax credits”), the Congressional Budget Office numbers say some lower-income older Americans who aren't yet eligible for Medicare could face out-of-pocket health costs several times as much as they do now. AHCA opponents have seized on the example of a 64-year-old making $26,500 who is paying $1,700 a year now and would pay $14,600 under the AHCA changes. Such high prices could drive these individuals out of the private insurance system entirely. And without insurance, critics say, patients are more likely to let health problems accumulate until they have to go to an emergency room to receive more expensive care. Certainly I have seen this in my own practice. Another issue raised by the CBO scoring is the number of uninsured Americans. It is predicted by CBO that under the current AHCA proposal the number of uninsured Americans will rise 24 million, from 28 million to 52 million, by 2026. But Speaker Ryan and President Trump say the CBO's numbers regarding future uninsured patients can't be trusted. And they say the CBO's financial projections can't be considered definitive because they plan more changes to health insurance with further reforms which will lower prices. “Phase II” of this process is to include as-yet unwritten regulations from HHS Secretary Tom Price. “Phase III” is separate legislation including reforms designed to increase competition among both consumers and insurance companies.Since this AHCA bill is being passed as part of the budget, it only needs a simple majority of 51 votes. However, the Phase III reforms which go beyond taxes and subsidies must be passed separately under regular Senate rules requiring 60 votes. One Phase III idea is allowing people to buy insurance across state lines; with the increased competition theoretically diving down the price. Another idea, which has already passed the House as the Small Business Health Fairness Act, would allow small businesses to pool together so they have the same leverage as large businesses in negotiating insurance plans for their employees. Phase III, should it happen, could also involve letting insurance companies and state insurance regulators offer a wider range of insurance products. The AHCA also wants to give state regulators more power in the area of Medicaid. Currently, Congress gives states matching funds based on how much the state spends on treating Medicaid patients. The ACHA would instead give “per capita block grants” to states based on the number of people enrolled in the program. The ACHA also seeks budgetary cost savings in Medicaid in other ways. The Medicaid expansion passed as part of Obamacare raised the eligibility level for Medicaid enrollees to 138 percent of the federal poverty level. Thirty-two states signed up for this expansion. The Trump / Ryan bill would phase out this expansion starting in the year 2020 – though it would include a generous grandfather clause for persons who had already signed up. Speaker Ryan and President Trump face a delicate balance in trying to get the bill through Congress. It is likely no Democrat will vote for a bill repealing Mr. Obama's signature initiative. Centrist Republicans worry about Medicaid enrollees and older Americans facing higher premiums losing coverage. Conservative Republicans, including the Freedom Caucus, say they won't vote for a bill that retains a system of subsidies and guaranteed-issue. Their skepticism is heightened given that the Phase III reforms – some of which have already passed the House – will need 60 votes to pass under Senate rules.President Trump is an accomplished salesman, but no matter how you look at it, he has a hard sell here getting this America Health Care Act through the House and the Senate. Even should he manage to do so, it is not entirely clear that his health care bill will save the federal government money, or that it will help solve American's health care woes.

It needn't cost the earth to be beautiful. Here are a few tips for people looking to save money on beauty products. This is a passion of mine since I know how much things actually cost to make and how much we are being ripped off as my website will show.

It is a fact that more than 20 million Americans today need professional help to get rid of alcohol and drug addiction. Most of the times this addiction pertains to some substance abuse, medical drugs abuse or alcohol but the actual problem is, the sufferers never realize that they need help and treatment to get rid of their nasty addictions.

I have to laugh at all these "experts" claiming that penis pumps have no place in enlargement techniques. Don't get me wrong, I don't advocate them either; but I understand the physiology behind their methodology and have read the scientific data. Yes, penis pumps do work. Not only that, but they are one of the best ways to enhance the same processes most "experts" are trying to sell you on.

Mesothelioma is a malignant tumor of the mesothelium caused by exposure to asbestos fibers. There is some important information one should be aware of if he is considering pursuing an asbestos mesothelioma lawsuit.

I really doubt Trump can make something better than ObamaCare. Actually, I'm sure that he can only destroy everything nice our ex-President gave us. And it's starting already. With all that anti-abortion company.

Reply

Leave a Reply.

Las Vegas EM FOAM Blog

A FREE AND OPEN-ACCESS MEDICAL EDUCATION BLOG BY THE RESIDENTS AND FACULTY OF LasVegasEM.

The information contained in this blog is for educational puposes only and is not intended to advocate specific medical practices. All opinions are our own and do not imply endorsement by our hospital or school of medicine. Any reference to patients has been redacted or intentionally altered to make identification impossible.

QUICK LINKS

LasVegasEMR.com is neither owned nor operated by the University of Nevada School of Medicine (UNSOM). It is financed and managed independently by a group of emergency physicians. This website is not supported financially, tech﻿nically, or otherwise by UNSOM nor by any other governmental entity. The affiliation with UNSOM and the UNSOM logo does not imply endorsement or approval of the content contained on these pages.